I would like to address the learning of psychodynamic psychotherapy, how it is presented to the psychiatry resident, and how it differs from other forms of treatment. It is important for residents to realize that psychodynamic psychotherapy is not so much only what one does in the second or third year of residency, behind the closed door of the clinic with the patient on a comfortable chair holding a Kleenex, but rather who one is—in the clinic, on the wards, in the general hospital. A psychodynamic stance can influence every aspect of our practice as psychiatrists.
It is equally important to say at the outset that, in my experience, there is no easy agreement on what is considered the practice of psychodynamic psychotherapy. Therapists who call themselves psychodynamic can have widely different approaches—both theoretical and technical—to the same clinical problem. At a discussion group at the last American Psychoanalytic Association Winter Meeting, a table of five psychoanalysts, a graduate psychologist and I, a psychiatry resident, could not agree on the definition of psychoanalysis. A sampling of definitions included: “There has to be interpretation, and the interpretations have to be used by the patient for change.” “You have to use the couch and there must be free association.” My own at the time, “A therapy in which regression and transference are predominant.” None met with uniform approval.
Jon Meyer, the president of APsaA, who was quoted recently in Psychiatric News (a publication of the American Psychiatric Association), said of psychodynamic treatments in general, “We have a fabulous product,” and of psychoanalysis in particular, “For those who need it, it does what nothing else will do.”
Psychiatry residents have to understand what is meant by psychodynamic psychotherapy, which is related to the question of what is meant by psychoanalysis, or what is meant by psychodynamics in general. We need to know what makes this treatment different from other psychotherapeutic treatments, such as CBT, interpersonal, supportive, and brief, that psychiatry residents are required to learn. Also, we need to know what psychodynamic psychotherapy is good for—what it can and cannot do and for whom.
There seems to be a belief that whenever the patient is talking and the resident is listening, psychotherapy is occurring. This may be true in a general way, but at some point in our training we must understand what this unique process is and how it can be so useful.
It can be discouraging for new trainees, as it was for me, to see their professors throw up their hands and say, “I don't know how this works, who does?” (Although I admired their honesty!)
There are non-specific factors in effective psychotherapy that transcend theoretical orientation. A recent meta-analysis of psychotherapeutic efficacy showed that nonspecific factors, i.e., dimensions that are shared by most psychotherapies, may account for more of the variance in treatment outcome than specific factors. This deserves emphasis in psychiatric training. Put another way, knowledge of dynamic theory, accuracy of interpretations or just plain brilliance does not necessarily make an effective psychotherapist. Successful formation of the therapeutic alliance, empathic listening, and planning treatment goals, as well as old-fashioned competence, are necessary for successful psychotherapy of any form. An important question is whether certain theories, techniques, or educational experiences best help residents master these non-specific factors.
Non-specific does not mean eclectic. An earlier meta-analysis concluded that adherence to a purity of treatment approach may itself be a non-specific factor related to efficacy. Could adhering to a conceptual framework of any kind produce better outcomes? In the case of psychodynamic therapy this idea has an important twist. Psychodynamic theory as it is taught in our residency emphasizes three or four “psychologies”—or different ways of listening in psychotherapy, with different sources of interpretation and different, sometimes opposite, interventions indicated in the same clinical situation (for example, interpreting idealization as a defense against aggression or accepting it as a deficit in need of repair)! On the one hand, this diversity is a tremendous richness and a source of pride to our field, which speaks to the developmental history of psychodynamic theory itself. On the other hand, it can be a reminder of divisions in our field, the memory of which we may be suppressing in our new ecumenism. Or it is both. But for the psychiatric trainee trying to learn what makes psychodynamic psychotherapy unique, important, effective, and a “fabulous product,” the diversity is a potential obstacle.
Some training analysts go so far as to say that this “listening with evenly hovering attention” can leave the patient feeling like the therapist is wishy-washy or has no substance. It is difficult to imagine learning psychodynamic psychotherapy without understanding the three or four psychologies of psychoanalysis, or the way they are presented in the books of the field's great teachers. In my own development as a psychotherapist, dialogue with many teachers and mentors continues to provoke and correct my understanding of our complex art. Learning this way means we have to work harder to define and teach exactly what our product is.
Paul Tiger, M.D., is a third-year resident at the Medical College of Wisconsin and Affiliated Hospitals in Milwaukee.